Provider Demographics
NPI:1689873192
Name:DAVIS, KEITH ROBERT (IDC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ROBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SYLVESTER RD
Mailing Address - Street 2:USS TOPEKA (SSN 754) FPO AP 96679-2410
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-3521
Mailing Address - Country:US
Mailing Address - Phone:619-553-0123
Mailing Address - Fax:619-553-0744
Practice Address - Street 1:140 SYLVESTER RD
Practice Address - Street 2:USS TOPEKA (SSN 754) FPO AP 96679-2410
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-3521
Practice Address - Country:US
Practice Address - Phone:619-553-0123
Practice Address - Fax:619-553-0744
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians